Paris Terror Attacks: How the 'White Plan' Medical Emergency Plan Was Implemented

Dr Isabelle Catala

November 18, 2015

PARIS ― On November 14, the French Minister for Health, Marisol Touraine, and the President of the French Republic, François Hollande, paid tribute to the Paris medical teams who helped treat those injured in the Paris attacks of Friday, November 13. It was thanks to the exemplary work done by these teams that there have only been three deaths from among the 100 injured who were classified as "Absolute Emergencies."

Two coordinated systems for dealing with the large number of injured were set up: disaster medical facilities on the sites of the attacks, and mobilization of the hospitals in the form of a White Plan. This type of response comes under the umbrella of the ORSAN plan (an acronym for a French phrase meaning, "organization of the response by the healthcare system to an exceptional medical situation"), which dates from 2014 and that encompasses the White Plans.

Medscape France spoke with a Paris SAMU emergency ambulance doctor and a Paris accident and emergency (A&E) physician, who explained how the healthcare personnel were mobilized.

At the Paris SAMU Emergency Ambulance Service

As soon as news arrived of the first injuries, a coordination unit was set up at the Paris SAMU (Service d'Aide Médicale Urgente, or Urgent Medical Aid Service), in Necker Hospital, in Paris. The SAMU building was secured by the police, because the risk of an attack on the coordination unit had been identified.

A medical response director and deputies were appointed to coordinate the operations on site jointly with the office of the prefect, the regional health agency, the police, the fire brigade, and the civil protection service. The SAMU and SMUR (Service Mobile d'Urgence et Reanimation, or Mobile Emergency and Resuscitation Service) emergency ambulance services from the suburbs were also called in, specifically, SAMU 93, because of the attacks at the Stade de France.

At the sites of the attacks, situations were managed differently, according to the location: for the attacks on bars and restaurants, following initial triage organized by the SAMU, the injured were taken directly to the Paris hospitals in which the hospital White Plan had been activated.

An advanced medical post was set up on Boulevard Voltaire, close to the Bataclan concert hall, which had been the target of an attack, using a system comparable to that employed in disaster medical care. The injured were classified as "Absolute Emergency," "Serious Emergency," and "Emergency." The advanced medical post had completed its triage work 2 hours after the end of the attack on the Bataclan concert hall.

Three Degrees of Emergency: U1, U2, U3

Most of the injured categorized as "Absolute Emergency U1" were sent directly to the hospital recovery rooms so that they were as close as possible to intensive care units and operating theaters. This generally concerned patients with gunshot wounds, often multiple, who required thoracic, digestive, and orthopedic surgery. The SAMU and fire brigade physicians took charge of these patients.

The injured categorized as "Relative Emergency U2" were transferred to the A&E wards in Paris or the near suburbs by the fire brigade or by civil protection and Red Cross services.

The less severely injured ("Slight Injuries U3") were treated on site and were instructed to consult an A&E department within the next few days if their condition so required.

Persons suffering psychological stress were invited to attend a consultation in a psychological support unit.

Dress Rehearsal by the Paris SAMU That Morning

On the morning of the attack, the emergency response teams at the Paris SAMU had conducted a rehearsal of the White Plan, simulating multisite terrorist attacks. This extraordinary timing suggests a maximum alert level, rather than an astonishing coincidence.

At the Hospitals

As soon as the scale of the attacks became known, the departmental, regional, and national White Plans were deployed. Within each hospital, the duty administrator was first informed, followed by the director, so that a crisis unit could be set up. Their role was to call their duty staff, to make beds available, and to evaluate the treatment capacity for the injured according to the type of injury and operating theater availability. Owing to the fact that many of the injuries were from gunshots, thoracic surgery units outside the Paris region were mobilized (even if in the end they did not take any patients).

The hospital directors and ward managers were asked to "empty" the A&E units of the patients who were present at the time of the attacks. These patients were sent to hospital beds that had been made available; generally, these were beds that had been reserved for scheduled surgery or for inpatients. As many inpatient emergency beds as possible were freed up.

The personnel who were not on call were required to be available to be contacted so that they could be called to their place of work if necessary. This avoided an influx of healthcare staff to a small number of hospitals.

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